Patient Clinical History Taking – VIDEO

https://www.youtube.com/watch?v=gsjKcQUsQY8

Patient health assessment

Core principles

Key steps

I´ve had a cough for a few days.

It´s driving me nuts, really.

How long has the cough been there for?

Have you got any other symptoms with that cough?

I have got quite sore throat. That´s quite bad as well.

Is it worse any particular time of the day or night?

Are able to swallow with that sore throat?

Phlegm/mucus/muck

Does it travel anywhere else, sort of radiation of pain

Has any other persons been affected.

Are there any relieving factors

Over-the-counters, nothing worked

What do you think it is?

I need some antibiotics

Is there any fever, any feeling shivery, shaky?

Breathlessness – have you got any breathing problems, chest tightness?

Is any green phlegm dripping at the back of your throat?

Have you had any unexplained weight loss?

Any recent travels abroad?

Key body systems – overall health

Do you suffer of headaches? How often?

Have you seen your doctor for that?

Have you ever had any head injuries?

What about your vision, do you wear glasses?

Do you ever suffer with nasal congestion? Or sinus problems?

With cats, they set me off. I must be alergic to cats.

Any change of tastes?

Do you get mouth ulcers?

Bowels working all right? Water works OK?

Sexual history

Are you in a relationship?

Are you heterosexual?

Do you use barrier methods? No, my girlfriend is on the pill.

What about your bones? Any joints problems?

No sleeping problems.

Feeling low moods?

Surgical history

Have you had any operations?

I had some sort of operation on my back 20 years ago – pilonidal sinus.

Medical history – patient and family

Have you or any first degree relatives ever suffered with jaundice when you see yourself go yellow?
(žloutenka)

Any anemia (iron deficiency)?

Have ever had a heart attack or any member of your family?

Any thyroid problems? (štítná žláza)

Any rheumatic fever (rheumatoid)? Revmatická horečka

I have got high blood pressure.

When was your blood pressure last checked?

When were you diagnosed with diabetes?

My father died two years ago of stroke.

Any cancers in the family?

Medicines

Do you take any prescribed medicines?

Do you know the dosage of the Ramipril?

Five milligrams every evening.

Allergies

Are you allergic to anything?

Do you have any drug allergies? Any food allergies?

Do you take any recreational drugs?

I had some over-the-counter cough medicine.

Have you had paracetamol recently?

Do you do any herbal remedies?

Social background

What´s your occupation?

Have you been lately exposed to dust or any new substances?

Are you happy with your work?

Where do you live?

Do you smoke?

How many cigarets do you smoke a day?

At what age did you start smoking?

Have you thought about giving up?

I would like to ask about your alcohol intake? Do you drink? What you normally drink?

And how about your diet, do you eat well?

Do you exercise?

Summary and confirmation

Is there anything else you would like to add?

Now we are going to check your vital signs and I´m going to examine you before we can decide what´s
going on with your sore throat and cough.